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Home
About Us
Providers and Staff
Testimonials
Digital Cookbook
Blog
FAQ’s
Refer a Friend
Site Terms
Semaglutide Injections
Semaglutide Injections / Results
Pricing Semaglutide In-Office
Candidate for Semaglutide?
Weight Loss
SvelteMD Classic Weight Loss Program
Our Program
Weight Loss Program Pricing
The Use of Appetite Suppressants
Pricing
Traditional Weight Loss Plan Pricing
Semaglutide Pricing
BioTE Pricing
Telehealth
Our Telehealth Process
Pricing Semaglutide Injections Telehealth
Candidate for Semaglutide?
Testosterone/Hormone Therapy
BioTE® Orlando
Pellet Pricing
Biote-Men-Quiz
Biote-Women-Quiz
Contact
IV Hydration Medical History Form
Date
Name
Phone
Email
Date of Birth
Allergies
Current Medications
1. Have you ever had prior IV nutrient infusion?
No
Yes
If so, when
Did you have problems with prior infusions including reactions, allergies, or access issues?
2. Do you have any of the following conditions?
None
End Stage Renal Disease
Cerebral Hemorrhage
Hyperparathyroidism
Congestive Heart Failure (CHF)
Myasthenia Gravis
Hypermagnesium
Kidney/Renal Disease
Hemolytic Anemia
Current UTI
Cardiac Arrhythmia
Low Blood Pressure
Kidney Stones
Liver disease
3. Have you been told that you need to start dialysis or are you currently on dialysis?
Yes
No
4. Are you taking or have you been told you need to take Digoxin?
Yes
No
5. Have you been told you have a decreased GFR or kidney problem?
Yes
No
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